Provider Demographics
NPI:1841773736
Name:CORCORAN, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12207 BEAVER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-8000
Mailing Address - Country:US
Mailing Address - Phone:804-874-4236
Mailing Address - Fax:
Practice Address - Street 1:8884 MENOKIN RD
Practice Address - Street 2:
Practice Address - City:MONTROSS
Practice Address - State:VA
Practice Address - Zip Code:22520-2934
Practice Address - Country:US
Practice Address - Phone:804-493-9818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12149311235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist